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Chapter 11 Ethical and Legal Foundations for Supervision Practice

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In a perfect world, supervisors would have only positive effects on others. Their actions always would be wise, virtuous, and just (see, e.g., Sen, 2009); but, of course, supervisors are only human, and so this is not the case. Ethical codes increase the extent to which professionals exhibit best behavior from the perspective of their profession; laws exist to help ensure minimally acceptable behavior toward the society they serve. The focus of this chapter is on supervisors’ dual responsibilities of comporting themselves legally and ethically while also preparing supervisees to do the same.

On the face of it, the very low incidence of ethical infractions by mental health professionals in both the United States (Van Horne, 2004) and Britain (Symons, Khele, Rogers, Turner, & Wheeler, 2011) seems reassuring. When the focus is specifically on supervisory behavior, the rates are even lower (Pope & Vetter, 1992), although Robiner (2008) did report that improper or inadequate supervision was the seventh most frequent reason for disciplinary action by psychology boards. However, these data concern ethical complaints and their adjudication. When supervisees describe supervisor behavior, the picture changes substantially. Ladany, Lehrman-Waterman, Molinaro, and Wolgast (1999), for example, found that a remarkable 51 percent of the supervisees they surveyed perceived their supervisors to have engaged in at least one ethical violation. Because supervisees reported that they then had discussed the perceived violation with their supervisors only 35 percent of the time, supervisors are not routinely getting this important feedback. An important qualifier of the Ladany et al. (1999) results is that not all unprofessional behavior is unethical, and supervisees are not necessarily prepared to make that discrimination (Gottlieb, Robinson, & Younggren, 2007); also, a seemingly contradictory finding by Bucky, Marques, Daly, Alley, and Karp (2010) is that 85 percent of supervisees surveyed rated their supervisors as “above average” in ethical integrity. Yet none of this diminishes the essential

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message from the Ladany et al. (1999) data: Supervisory ethical misbehavior is unacceptably extensive.

The manner in which supervisors exercise their ethical responsibilities can have multiple effects, including those on (a) the supervisory relationship, (b) the supervisee, (c) the clients being served by the supervisees, and (d) even the general public (see Goodyear & Rodolfa, 2012). Moreover, the effects of any given supervisor behavior typically will be on more than one of these four domains.

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The Close But Imperfect Relationship Between Ethics Codes and the Law At times, ethical codes and the law can be at odds with one another (see Knapp, Gottlieb, Berman, & Handelsman, 2007; Pope & Bajt, 1988; Pope & Vasquez, 2011). But in general, they overlap, however imperfectly. In fact, the law often qualifies how an ethical principle is implemented. For example, the ethical principle that client–therapist confidentiality should be sacrosanct is qualified by the law so that some mental health professionals, but not others, have the added legal protection of privileged communication; many jurisdictions require therapists to break confidentiality when there is suspected child or elder abuse; and case law from the Tarasoff lawsuit (discussed later) requires the therapist to breach confidentiality in specific ways when a client threatens to harm others.

Another example of the interplay between ethics and the law is in the ways in which sanctions for ethical misconduct can support or even trigger legal sanctions, and the reverse is also true. In fact, ethical standards can become legally binding (see Meyer, Landis, & Hays, 1988), particularly in civil cases, because they may be used by the courts to determine professional duty, and they are indirectly influential because they guide the thinking of others in the field who may be asked to testify. For a professional to be considered liable for civil damages, it is generally accepted that she or he must have acted outside the bounds of accepted professional practice (Guest & Dooley, 1999; Ogloff & Olley, 1998; Remley & Herlihy, 2001).

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Yet another distinction is that whereas ethics codes are grounded on relatively universal and enduring principles (see, e.g., Beauchamp & Childress, 2001), laws vary across time and jurisdiction. Weinstein (2007) illustrates this point by noting that in the United States, both slavery and the use of children for labor in mines and factories once were legal, but now are not; whereas the laws changed, the ethical issues relevant to slavery and child labor are the same now as they ever have been.

In short, ethical and legal issues related to clinical supervision are closely related, but can be sufficiently differentiated to warrant separate coverage. Therefore, we organize this chapter in three sections: the first addresses ethical issues; the second addresses legal issues; and the third addresses the teaching of ethical decision making. We conclude the chapter with a discussion of the supervisor’s role in preparing ethical practitioners.

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Ethical Issues In Clinical Supervision Ethics is a branch of philosophy concerned with what is moral or good (see, e.g., MacIntyre, 1998). One of its practical expressions is in the ethical codes the professions adopt that serve as guidelines for member decision making and, when necessary, provide a basis for regulating member behavior—the contract with society we discuss in Chapter 1 .

Each mental health profession (e.g., counseling, psychology, social work) has its own ethics code; most professions then have separate ethical codes by country, as ethics codes typically are developed by national associations of the particular profession. In spite of this proliferation of ethical codes, a number of studies have demonstrated that mental health professionals encounter similar ethical dilemmas, regardless of profession and country (see, e.g., Pettifor & Sawchuk, 2006).

Common moral principles also undergird most ethics codes. In his now- classic work, Ross (1930) suggests that some moral principles are what he terms prima facie obligations—those that must be fulfilled unless they compete in a particular circumstance with an equal or stronger obligation. Ross’s work was foundational for that of Beauchamp and Childress (2001; see also Bersoff & Koeppl, 1993; Kitchener, 1984), who describe the first four of the following moral principles; the fifth is from the ethical guidelines at the outset of American Psychological Association’s (APA’s) ethical code (APA, 2002).

1. Respect for Autonomy: concerning respect for a person’s right to make his or her own choices; manifest, for example, in the ethical

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demand to provide informed consent. 2. Beneficence: concerns contributing to the well-being of others and

optimizing benefits over risks; manifest, for example, in the ethical demand for competence.

3. Nonmaleficence: captured in the Hippocratic oath and stated as “Above all, do no harm” (in Latin, Primum no nocere); as with beneficence, this is manifest in the ethical demand for competence.

4. Justice: concerning fairness in distributing risks, benefits, and costs; manifest, for example, in adhering to due process.

5. Fidelity: concerning keeping promises; manifest in, for example, adhering to agreed-on processes and not abandoning the supervisee.

In summary, clinical supervisors in all countries and across professions address substantively similar ethical issues. In determining what those issues might be for supervisors, Ladany et al. (1999) suggests a taxonomy with 15 of those issues specific to supervision and shown in Figure 11.1 , along with the proportion of supervisees in their study who reported having experienced each issue with their supervisors (more on this later).

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FIGURE 11.1 Percentage of Supervisees Who Described One or More Perceived Ethical Breaches in Each of 15 Categories (from Ladany et al., 1999)

In what follows, we address a smaller set of issues than Ladany et al. suggest, although their issues certainly are embedded in those we cover. We cover, in turn, due process, informed consent, multiple relationships, supervisor and supervisee competence, confidentiality, and business- related supervisory issues.

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Due Process

Whereas due process is an ethical issue for supervisors, it typically is exercised in an organizational context—that is, an academic training program or an internship. Due process concerns ensuring that (a) notice and hearing is given before an important right can be removed from a person, and that (b) the criteria being used are fair (Disney & Stephens, 1994). We address it here as an ethical matter, although it is a legal one as well. For example, the U.S. Constitution’s 14th Amendment asserts that “nor shall any State deprive any person of life, liberty, or property, without due process of law; nor deny to any person within its jurisdiction the equal protection of the laws.”

Due process has two components (see Forrest, Elman, Gizara, & Vacha- Haase, 1999; Gilfoyle, 2008):

Substantive due process concerns the “substance of a decision, rather than the process by which it was made, in general using the standard of whether a decision was ‘arbitrary or capricious’” (Gilfolyle, 2008, p. 203). Procedural due process has to do with the individual’s right to be notified; to be apprised of the academic and performance requirements and program regulations, receive notice of any deficiencies, be evaluated regularly, and have an opportunity to be heard if their deficiencies have led to a change in status (e.g., put on probation).

Ethical guidelines developed specifically for supervisors (Center for Credentialing and Education, 2001; Supervision Interest Network, 1993) address the issue of due process concerning supervisees most directly (see the Supervisor’s Toolbox). For example, Section 2.14 of the Ethical

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Guidelines for Counseling Supervisors (Supervision Interest Network, 1993) states:

Supervisors should incorporate the principles of informed consent and participation; clarity of requirements, expectations, roles and rules; and due process and appeal into the establishment of policies and procedures of their institution, program, courses, and individual supervisory relationships.

The most blatant violation of this guideline occurs when a supervisee is given a negative final evaluation or dismissed from a training program or job without having had either prior warning that his or her performance was inadequate or a reasonable amount of time to improve (a procedural due process issue).

A full due process procedure should ensure that the supervisee in question is guaranteed an objective and respectful review of the situation, as well as the expert opinions of both professionals and the person who initiated the concern. Although most supervisees do not challenge violations of due process rights, some have litigated (cf. Disney & Stephens, 1994; Forrest et al., 1999; Gilfoyle, 2008; Jaschik, 2012; Knoff & Prout, 1985; Meyer, 1980). However, when due process procedures have been followed, the courts have shown great deference to faculty evaluations (Forrest et al., 1999; Gilfoyle, 2008; McAdams, Foster, & Ward, 2007). Supervisors and training programs can find a number of effective examples of due process procedures on the Association of Psychology Postdoctoral and Internship Centers’ (APPIC’s) website: www.APPIC.org.

Forrest et al. (1999), Frame and Stevens-Smith (1995), and McAdams et al. (2007) propose the programs develop policy statements to guide evaluation processes (i.e., procedural due process) and that they establish descriptive criteria about personal characteristics that are determined to be essential for success as a mental health practitioner (i.e., substantive due

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process). These criteria must then be used for ongoing evaluation of students during their training program. In short, students’ due process rights are protected both by published policy statements and criteria, and by the availability of the regular evaluations. When students are found to be in jeopardy, Frame and Stevens-Smith (1995) use a procedure very similar to that described by Lamb, Cochran, and Jackson (1991).

Example :

“Hannah” is in a master’s program in mental health counseling. She has completed 10 courses in the program and is currently in practicum. Hannah has received a great deal of formative feedback throughout the practicum indicating that she has many areas that need improvement. At the conclusion of the practicum, Hannah’s instructor assigns Hannah a grade of F for the course. At this time, Hannah is informed that a failing grade in the practicum is grounds for dismissal from the program. Hannah is told that she may retake the practicum one time, but that the faculty are not optimistic that she will improve enough to receive a B or better, a condition for her continuing in the program. Although Hannah knew that she was not doing as well in the practicum as some others, she had no awareness that she was in danger of being terminated from the program until the final evaluation.

It is likely that Hannah will take the advice of the faculty and discontinue the training program. However, have her due process rights been protected? How vulnerable is her practicum instructor and the program if she should decide to challenge their decision? Even if Hannah does not appeal, what are the potential systemic implications of such a process? Whereas there is no ill will evident in the action of the faculty and no indication that their decision was capricious or arbitrary, did the process they followed protect the student adequately, and was it legally defensible?

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Informed Consent

Research participants, therapy clients, and supervisees all have the right both (a) to the best available information about what they are involving themselves in, including its risks and benefits; and (b) to choose whether to participate based on that information. In short, they have the right to informed consent to their participation. It is fair to assert that there is no ethical standard as far-reaching as informed consent for the practice of psychotherapy. This is true as well for supervision. Ellis (2010), for example, observes that the legal standard of care in supervision is to provide informed consent or a supervision contract. Yet Ellis found that “less than 19% of supervisors provided informed consent and only 41% used a supervision contract” (Ellis, 2010, p. 111).

In fact, the supervisor has three levels of responsibility with respect to informed consent, and must do the following:

1. Provide the supervisee with the opportunity for informed consent 2. Determine that the supervisee informs clients about the parameters

of therapy 3. Determine that the supervisee informs clients about parameters of

supervision that will affect them.

We discuss each of these in turn.

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Informed Consent with Supervisees Regarding their Supervision. It is best practice that supervisees be well informed about the processes and expectations of supervision (Knapp & VandeCreek, 2006). One mechanism to accomplish this is the use of a supervision contract (e.g., Sutter, McPherson, & Geeseman, 2002; see also the Supervision Toolbox).

Supervisors should clarify their gatekeeping responsibilities with supervisees at the outset of supervision (Russell et al., 2007), so that supervisees enter the supervisory experience knowing the conditions necessary for their success or advancement, including the personal and interpersonal competencies they will be required to demonstrate (Forrest et al., 1999). It also should be clear to each member of the team what their respective responsibilities are.

Supervisees also should be apprised of the supervision methods that will be used, the time that will be allotted for supervision, the expectations of the supervisor, the theoretical orientation of the supervisor, and the type of documentation required for supervision (Cohen, 1987; McCarthy, Sugden, Koker, Lamendola, Maurer, & Renninger, 1995; Pope & Vasquez, 2011). Simply put, any surprises the supervisee encounters should be due to the learning process itself and the complexity of human problems; and not to oversights on the part of the supervisor.

Thomas (2007) notes that informed consent is only partially applicable to supervision, because once a person enters a training program (thus entering a profession), that person’s options become limited. Requirements for success (e.g., program completion, licensure) are largely predetermined, although information should have been available to that student prior to entering the training program. The supervisor’s role from

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this angle stresses the function of the gatekeeper. Barnett (2007), however, emphasizes the importance of a productive relationship to effective supervision: Although measuring the supervisee’s performance against standards is not necessarily in any opposition to forming a supportive relationship with a supervisee, these dual tasks require skill and open communication. They also may require ongoing supervision of supervision.

If there is a possibility that personal counseling will be mandated or even recommended for any trainees in a given program, all trainees should be cognizant of this practice on entering the program (Whiston & Emerson, 1989). Standard 7.02 in the APA’s Ethical Principles of Psychologists and Code of Conduct (APA, 2002) is very explicit about this. As well, Standard 7.04 states that prospective students must understand before entering a program if they will be required to participate in situations (e.g., experiential groups) that require them to self-disclose personal information (Illfelder-Kaye, 2002).

Independent of the issue of informed consent, referring trainees to therapy is problematic, given the absence of evidence of therapy’s efficacy to remediate supervisee functioning (Russell, DuPree, Beggs, Peterson, & Anderson, 2007). Also, Russell et al. note that to refer students to therapy implies a diagnosis, which then blends the educational relationship between supervisor and trainee with one that is more clinical. They also stress, as do others, that a referral to therapy opens the door for the supervisee to claim discrimination based on a disability by virtue of the Americans with Disabilities Act. Their conclusion, therefore, is that “Psychotherapy as an integral part of training for supportive and preventive purposes is different from selecting out students for therapy as a part of remediation” (Russell et al., 2007, p. 238).

Consider the following examples:

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1. Latoya is in her predoctoral psychology internship, working with very difficult clients. In supervision, she shares that one client in particular has been “getting to her,” most likely because some of the client’s situation is so similar to Latoya’s past. Latoya’s supervisor immediately suggests that Latoya receive counseling regarding this issue. When Latoya says that she believes her past therapy was sufficient and that she would prefer to view the situation as a supervision one, her supervisor states that she will only continue to work with Latoya if she commits to counseling.

2. Ronald, a student in a professional counseling master’s program, makes an appointment to see his academic advisor to discuss his internship now that he is near the end of his training program. He plans to do his internship in a local mental health agency. His advisor tells Ronald that the faculty recently evaluated students and that he was viewed as not having the capacity to be successful in clinical work. It was suggested that he pursue an internship in a “softer” area, such as career counseling. Ronald states that he has no interest in career counseling. Ronald’s advisor states that such an internship site is the only type that will be approved for him.

3. Ruth has been assigned to a local mental health hospital for her field placement to work with patients who are preparing to be discharged. It is her first day at the site, and she is meeting with her site supervisor. He gives her a form to fill out that asks for information regarding her student malpractice insurance. When Ruth tells her supervisor that she does not carry such insurance, he advises her that it is their policy not to accept any student who does not have insurance. The supervisor also expresses some surprise, because this has always been the hospital’s policy, and Ruth is not the first student to be assigned to them from her training program.

In each situation, how egregious do you find the violation of the supervisee’s right to informed consent? To what extent can institutional materials cover issues of consent? How might each situation have been handled to better address the rights of the supervisee?

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Informed Consent with Clients Regarding Treatment. Most who are reading this text already understand how essential it is that clients have the opportunity for informed consent to treatment. As supervisors, they are responsible for ensuring that their supervisees provide this to the clients they are serving.

Haas (1991) suggests seven categories of information that, if provided, constitute necessary and sufficient informed consent. The first of these concerns risks of treatment, which may range from mild (e.g., embarrassment if others knew) to serious (e.g., the risk of terminating a marriage if one begins to address chronic relationship issues). Haas’s second category is the benefits of treatment.

Haas’s (1991) third category encompasses the logistics of treatment, including the length of sessions, cost, opportunity for telephone consultations, and so on. It also discusses any limits with respect to numbers of sessions, such as those that may be imposed by agency policy or insurance parameters (Acuff et al., 1999; Haas & Cummings, 1991) or supervisee availability (e.g., being assigned to a site for only a limited training period).

Haas’ fourth category includes information about the type of counseling or therapy that clients will be offered. If one is behaviorally oriented and requires homework, if the supervisee is in training as a marriage and family therapist and requires additional family members to be present, or if one’s approach to working with particular issues includes the use of group work, such stipulations should be explained at the outset of therapy. Disney and Stephens (1994) suggest that preferred alternatives to the type of

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treatment being suggested, as well as the risks of receiving no treatment at all, should be explained at this time as well.

Example :

Julian, a supervisee in a mental health agency, has been providing individual therapy to Ellen for four months. It has become apparent to him that Ellen and her husband need marriage counseling, an intervention in which he has been trained. He very much wants to follow this case to its conclusion, and without discussing alternatives, Julian suggests that Ellen bring her husband to the next session. Ellen says that she is relieved that he is willing to work with them. She was afraid that Julian would refer them to another therapist. Having Julian work with both her and her husband is exactly what she was hoping for.

In this example, we must consider whether Ellen or her husband has been given the opportunity to provide appropriate informed consent. Is there information about the therapy process that Julian should have offered to help them make the best decision for their present situation? At the very least, Julian has erred in not discussing alternatives, and his supervisor must now help Julian backtrack. If the supervisor had any inkling that marital therapy might be indicated, the supervisor was negligent for not coaching Julian regarding the client’s informed consent rights, as well as her husband’s.

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Informed Consent with Clients Regarding Supervision of Their Treatment. The client must be aware not only of therapeutic procedures, but also of supervision procedures. The client needs to know, for example, whether sessions will be taped or observed, who will be involved in supervision (e.g., one person, a team, members of a supervision group), and how intrusive the supervision will be.

The final three of Haas’s (1991) informed consent categories are all supervision related, and one of these is information to the client about emergency procedures. The supervisor always should be involved in an emergency situation. Clients should know if direct access to the therapist is available in case of emergency. Will the supervisor be available to the client?

Next is confidentiality. “Supervisees place themselves in a position to be sued for invasion of privacy and breach of confidentiality if they do not inform their clients that they will be discussing sessions with their supervisor” (Disney & Stephens, 1994, p. 50). Most training programs use written forms to alert clients of the conditions of supervision. It may be wise for the supervisor to meet with clients personally before the outset of therapy for a number of reasons: (a) By meeting the supervisor directly, the client usually is more comfortable with the prospect of supervision; (b) it gives the supervisor an opportunity to model for trainees the kind of direct and open communication necessary to ensure informed consent; and (c) by not going through the trainee to communicate with clients, it is one less way that the supervisor could be vicariously responsible should the trainee not be clear or thorough.

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Finally, Haas (1991) suggests that clients understand the provider’s qualifications. Several authors (e.g., Disney & Stephens, 1994; Harrar, VandeCreek, & Knapp, 1990; Knapp & VandeCreek, 1997; Pope & Vasquez, 2011; Worthington, Tan, & Poulin, 2002) note that it is vitally important for ethical and legal reasons that clients understand when they are in therapy with a supervisee who is in training. Any attempt to obscure the status of a supervisee may expose both supervisee and supervisor to civil suits alleging fraud, misrepresentation, deceit, and lack of informed consent.

Even when clients are aware that their therapist is under supervision, informed consent can be compromised when trainees downplay the parameters of supervision. Situations occur when supervisees use ambiguous language, such as, “If it’s all right with you, I’ll be audiotaping our session,” when what they mean is, “I am required to audiotape our sessions if I am to work with you.” This leaves the trainee in the awkward position of setting an unwise precedent, or of having to backpedal to explain the true conditions of therapy and supervision, and our experience is that clients sense the ambivalence and can become less inclined to give permission to record.

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Example :

Beth is a social worker who counsels women who have experienced domestic violence. She is well trained to do initial interviews with women in crisis, and her supervisor is confident in Beth’s abilities to carry out these interviews without taping them. In addition, there is the obvious concern that the use of audiotape would be insensitive to women who are frightened and vulnerable during the interview. The conditions of supervision, however, require Beth to audiotape all subsequent sessions.

Janell was one of Beth’s interviewees. After the initial session, Janell decided that she was ready to receive counseling regarding her abusive marriage. She explained to Beth that she was afraid of her husband’s reaction to counseling, so she made her first appointment for a day when she knew he would be out of town. When Janell arrived for counseling, Beth discussed the conditions of counseling, including the requirement that she audiotape sessions for supervision. Janell became quite upset and told Beth that she never would have agreed to counseling if she had known that the sessions would not be held in strictest confidence. Beth attempted to explain that would still be the case, but Janell left and did not return.

How do you react to Beth’s method of handling this situation? Were Janell’s informed consent rights violated? What alternatives did Beth have that would protect both her and her client?

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Multiple Relationships

Multiple relationships (dual relationships in earlier literature) occur when people have more than one social role in relationship toward each other. For example, a person may be a student in a professor’s class and also work as that professor’s research assistant. Such situations are common and not necessarily unethical. They become problemmatic when (a) there is a power differential between the two parties and (b) the multiple roles they have in relationship to each other puts the person with less power is put at risk for exploitation or harm.

The metaphor often invoked in discussions of multiple relationships is that of a boundary that encloses expected professional roles. Those boundaries need not, however, be completely rigid. In fact, Vasquez (2007), alludes to the usefulness of maintaining “permeable” (p. 407) boundaries, particularly when working with clients or supervisees whose cultural expectations for these roles may differ from that of the dominant culture. Barnett (2007) similarly pointed out the usefulness of relaxing boundaries when a client offers a small gift or might profit from having the session extended because she or he is experiencing a crisis. As Gabbard and Crisp-Han (2010) put it so well, “One must not construe boundaries as an admonition against being human” (p. 371).

It is important, then, to consider the distinction Gutheil and Gabbard (1993) make between boundary crossing and boundary violations:

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we should adopt the convention that “boundary crossing”. . . is a descriptive term neither laudatory nor pejorative. An assessor could then determine the impact of a boundary crossing on a case-by-case basis that takes into account the context and situation-specific facts, such as the possible harmfulness of this crossing to this patient. A violation, then, represents a harmful crossing, a transgression, of a boundary. (p. 190)

Fly, van Bark, Weinman, Kitchener, and Lang (1997) confirm in their work that boundary transgressions (sexual and nonsexual) were among the most common ethical transgressions among psychology supervisees, second only to violations of confidentiality. These two categories of ethical transgressions combined accounted for 45 percent of the total reported by training directors.

As is true of many of the ethical issues we address here, supervisors must address multiple relationships on two fronts: Educating supervisees and ensuring that they are not engaging in inappropriate multiple relationships with clients, and ensuring that they are not themselves engaging in inappropriate multiple relationships with their supervisees. We address each in turn.

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Multiple Relationships between Supervisees and Clients. There are various types of problematic multiple relationships in which therapists might engage with their clients, including, for example, providing therapy to a family member or borrowing money from a client. However, probably the most flagrant is a sexual relationship with the client. The power differential between therapist and client creates a substantial risk of exploitation, even should the client express the belief that she or he is voluntarily entering the sexual relationship. Ethics codes, therefore, prohibit these relationships (e.g., ACA, 2005; APA, 2002), and in most jurisdictions, they are grounds for revocation of licensure or certification. Supervisors are responsible for ensuring that supervisees understand the definition of a multiple relationship and avoid all such relationships with clients.

The literature concerning therapist misconduct with clients is vast and cannot be fully addressed here; however, a few authors study multiple relationships as a supervision issue. Specifically, we speak to the monitoring of relationships between supervisees and clients and to assisting supervisees in ways that reduce the likelihood of their involvement in exploitative relationships in the future.

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Preventing Supervisee Ethical Transgressions.

Although there is no foolproof way to ensure the ethical behavior of supervisees, several authors encourage a proactive supervisor posture (Koenig & Spano, 2003; Ladany, Friedlander, & Nelson, 2005). Most professional literature to date addressing supervisee transgressions focuses on sexual intimacies with clients. Among the most common strategies recommended are preventive education (Samuel & Gorton, 1998) and honest discussion between supervisors and supervisees about the possibility, if not the probability, of occasional sexual attraction to clients, of supervisors to supervisees, or the converse for each dyad (Bridges & Wohlberg, 1999; Hamilton & Spruill, 1999; Ladany & Melincoff, 1999; Ladany, O’Brien, Hill, Melincoff, Knox, & Petersen, 1997; Ladany et al., 2005).

Because persons attracted to mental health fields often have unresolved personal issues, supervisors should not be surprised that supervisees may need their assistance negotiating and maintain boundaries (Maki & Bernard, 2007). Hamilton and Spruill (1999) speculate that supervisee vulnerabilities to boundary transgressions include loneliness, prior paraprofessional or friendship “counseling” experiences in which levels of intimacy were higher than the professional norm, and failure to recognize ethical conflicts. They also criticize supervisors for not addressing sexual attraction to clients as normative and for stereotyping the problem in a sexist manner.

As with other sensitive issues, it is imperative that the supervisor accept responsibility for raising the topic. Ladany et al. (1997) found that unless this happens, only about half of supervisees who experience sexual attraction to clients will disclose it to their supervisors. In a related study, Heru, Strong, Price, and Recupero (2004) found that supervisees were more reluctant than supervisors to address sexual topics, including sexual

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attraction, during supervision. Gabbard and Crisp-Han (2010) suggest that supervisors tell supervisees, “If there is anything at all that you feel like concealing from me, that is probably the most important thing to discuss” (p. 371). Bridges (1999) further emphasizes the importance of supervisor openness and candor in assisting supervisees to manage intense feelings. “Ethical supervision is embedded in a clearly articulated supervisor– student relationship that monitors misuse of power and boundary crossings, yet is capable of deeply personal discourse” (p. 218).

Hamilton and Spruill (1999) suggest that prior to seeing clients, all supervisees receive instruction in the following:

1. The powerful effects of attraction of familiarity, similarity, self- disclosure, and physical closeness

2. Testimonials from well-respected clinicians about their encounters with sexual attraction in therapy

3. Specific actions to take when feelings of attraction arise, with emphasis on the importance of supervision

4. Suspected risk factors for and signs of client–therapist intimacy 5. Consequences of therapist sexual misconduct on the client �. Social skills training to increase skill and decrease anxiety related to

enacting ethical behavior 7. A clear explanation of program policy regarding ethical

transgressions, with emphasis on a clear distinction between feelings that are expected and actions that are unacceptable. (p. 320)

Offering this kind of information in a group format might reduce the reluctance of any individual supervisee to address the topic.

Ladany et al. (2005) suggest introducing the topic of sexual attraction very early in supervision. They argue that including such topics in an orientation

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to supervision normalizes them, making it easier to discuss them should they emerge during supervision. Once such groundwork has been established, they encourage supervisors to

Recognize what they refer to as markers of a potential boundary vulnerability, both overt (e.g., supervisee shares strong feelings about a client) or covert (e.g., supervisee dresses more attractively on days a particular client is scheduled). Walker and Clark (1999) note similar cues and include inappropriate gift giving, off-hours telephone calls, and “overdoing, overprotecting, and overidentifying” (p. 1438). Engage supervisees in discussion about their feelings; assess their knowledge of ethical standards; normalize the experience (if, indeed, an attraction is experienced); focus on any potential countertransference issues that may be operating; and finally, focus on how the attraction can be managed without negatively affecting the therapeutic process.

Ladany et al. suggest a similar process for a case in which the attraction is between the supervisor and supervisee.

Finally, the use of a professional disclosure statement (PDS), both for supervision (Blackwell, Strohmer, Belcas, & Burton, 2002; Cobia & Boes, 2000) and counseling and for therapy, are well advised as deterrents to boundary violations. A PDS, which includes details about one’s training and experience as well as about such issues as confidentiality, has the potential of alerting both supervisee and client to the professional nature of the relationship. It also typically includes contact information for an outside authority should there be some concern about what has transpired in the relationship. This alone, it would seem, communicates a high regard for professionalism and integrity. (See the Supervisor’s Toolbox and Fall & Sutton, 2004, for examples of a PDS.)

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Multiple Relationships between Supervisor and Supervisee. Supervisors often have more than one professional relationship with a supervisee, and these are not necessarily problematic (Gottlieb, Robinson, & Younggren, 2007). Behnke (2005), for example, observes

Our supervisees are also our students, research assistants, co-authors, and sometimes our friends. . . . These multiple roles often coexist productively, but when they do not the supervisor must explore competing values and interests to resolve potentially harmful tensions. (p. 90)

Simply put, what makes a multiple relationship unethical is the likelihood that it will impair the supervisor’s judgment and the risk to the supervisee of exploitation (Hall, 1988b). These factors can come into play when, for example, doctoral students supervise master’s students in the same program (Scarborough, Bernard, & Morse, 2006).

As a useful heuristic, Pearson and Piazza (1997) suggest five types of multiple role of which supervisors should be aware:

1. Circumstantial multiple roles: multiple relationships that happen by coincidence; for example, a supervisor’s adult son begins dating a young woman who turns out to be a student in his mother’s practicum class.

2. Structured multiple professional roles: when supervisor and supervisee have more than one professional role. This is what is usually being referred to when authors note that multiple relationships are ubiquitous to doctoral training programs.

3. Shifts in professional roles: for example, when a doctoral student who was formerly a classmate in a course with a master’s student

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becomes that student’s practicum supervisor. 4. Personal and professional role conflicts: includes preexisting

professional relationships followed by a personal relationship, or a personal relationship followed by a professional one.

5. The predatory professional: those who deliberately seduce or exploit others for their personal gain.

As with the literature regarding supervisees and clients, the type of multiple relationship between supervisor and supervisee that has received the most attention is sexual involvement between them. The literature concerning those issues tells us that:

1. There is some evidence that rates of faculty–student sexual contacts has been dropping. Reported percentages had been reported in the 12–14 percent range (Pope, Levenson, and Schover, 1979; Robinson & Reid, 1985; Rubin, Hampton, & McManus, 1997), with one ranging as high as 17 percent (Glaser & Thorpe, 1986). However, more recent rates have been in the single digits, ranging from 2 percent (Zakrzewski, 2006) to 6 percent (Miller & Larrabee, 1995) and 7 percent (Thoreson, Morrow, Frazier, & Kerstner, 1990)

2. Even when the relationship “felt” consensual to the student at the time, former students looking back saw them as coercive and even harmful. Glaser and Thorpe (1986) found that in retrospect, 51 percent of former students who had participated in a multiple relationship saw some degree of coercion. Most respondents in Robinson and Reid’s (1986) study judged that the relationships had been detrimental to both parties.

3. A higher proportion of female students have been involved in sexual contact with male faculty members (Pope et al., 1979; Tabachnick, Keith-Spiegel, & Pope, 1991; Zakrzewski, 2006).

4. Two studies (Bartell & Rubin, 1990; Rubin, Hampton, & McManus, 1997) found that sexual contact as a student with a faculty member

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may increase the likelihood of similar behavior once that student becomes a faculty member, although a third s